Abby Fox (Intro): Welcome to the Still Caring Podcast, presented by Stillwater Medical.

Joe Akin (Intro): Here, community is at the heart of healthcare.

Katon Lunsford (Intro): Through honest conversations and shared experiences

Abby Fox (Intro): We explore what it means to care for our health—

Joe Akin (Intro): and each other.

Katon Lunsford (Intro): Because better health takes a village and you're part of ours.

Abby Fox (Host): Hello and welcome to Still Caring the podcast from Stillwater Medical. I am Abby Fox, the PR and Marketing Manager here at Stillwater Medical. And I am joined today by Dr. Daniel Roton. Thank you so much for being in the studio with us.

Daniel Roton, MD: Of course, Abby, it's a pleasure. Thanks for having me.

Host: Absolutely. Well, let's just dive right in and tell us a little bit about when did Stillwater become home for you, and what has that looked like? Tell us about your background.

Daniel Roton, MD: Well, Stillwater became home the day I was born. I was born in Stillwater Medical Center, and I grew up in Stillwater, went to Stillwater High School, was a pioneer, played football. And my entire childhood was here. I left to go do my medical training, went to undergraduate school, and then did medical school elsewhere. And then, when the opportunity came to come back and work here in Stillwater, it felt just right. And so, it's been home since that time, and it's been a blessing.

Host: Is that something you would've anticipated that you would come back after graduating?

Daniel Roton, MD: No, it was not initially. You know, whenever I was in high school, I wanted to branch out, spread my wings and things like that. In fact, I remember my mom, when I was a senior in high school, she laid out two college applications, one to OU and one to OSU, and she said, "I don't care which one pick. You're picking one today." And I knew that I wanted to just spread out and spread my wings a little bit. So, I picked the OU one, went to OU for undergrad. And I never would've thought in a million years that I would be coming back to work at Stillwater Medical Center.

But when the opportunity arose, my old physical therapist is actually the one that reached out first, kind of offered the position to me, and I knew that pulmonary care was something that was lacking here in Stillwater. My grandparents both had lung issues, and they had to do a lot of traveling for their doctor's offices appointments and things like that. And so, being able to fill that gap here in my hometown was an opportunity I couldn't pass up.

Host: That's amazing. So for our listeners that don't know a lot about pulmonology, tell them what that is and what you do as a pulmonologist.

Daniel Roton, MD: Yeah. So, I do find I've stopped saying pulmonology to a lot of people. You know, I say I'm a lung doctor," that's what I am. So, it's a subset of internal medicine. And what got me into it or interested in it was actually the critical care side. So, most pulmonologists are double board-certified in pulmonary medicine, which is lungs, and then critical care, which is all things ICU. And the critical care side is actually what attracted me to the field first. I loved the intensity, the decisions, that just short response time, and the adrenaline essentially of being in the ICU setting, taking care of the sickest of the sick patients.

I also still love the critical care side of it, because you're able to develop a relationship with patients and their families at their most vulnerable time that I think is very unique. It's unlike any other aspect of medicine that I have been a part of. That critical care setting is a unique experience where people are at their most vulnerable and you're there to help guide them through it and the trust that is built in such a short amount of time is really nothing like any other type of medical relationship, as opposed to like primary care where those relationships happen over years. Critical care really does happen in a short amount of time, and I like that the best about critical care.

Along the way, I developed a passion for pulmonology. They always say that to people who are thinking about going into the field that ICU is what'll bring you there, but people stay for the pulmonology. And I think that's true. Pulmonary disease is a really broad specialty. It has a whole host of diseases that can affect the lungs. And it's a field that I look forward to spending the life time learning more about. Honestly, I think, I will be learning more and more about it up until the day I retire, because that depth is needed in order to truly understand it. So, it's really enjoyable.

Host: And it's developing all the time, right? Like, there are new technologies and new things available at any moment, which has to be exciting as a physician too.

Daniel Roton, MD: Very exciting. I think I am in the right field at the right time. It's very attractive and rewarding for that specifically. Like, we're actually able to do things for a certain subset of these diseases that, for 50, 60 years, there was just really not much that could be done. And now, all of a sudden things are coming out, technology is happening, that we are making life-changing interventions early on in disease courses that are completely changing the trajectory of people's lives. And that's really exciting.

Host: One of those that we've had a chance to talk about is lung cancer specifically. So, talk to us a little bit about lung cancer detection and kind of how that has changed recently, and what we're able to do now.

Daniel Roton, MD: So, I mean, it is changing just, I think, since I've been here and since the last time you and I have spoke. It's a rapidly evolving field. Lung cancer is a big problem. It's the number one cause of cancer related deaths in the United States. And it's a big problem in Oklahoma as well. I think a big portion of that is just the smoking prevalence.

And the problem with lung cancer is you don't develop any symptoms until it's progressive. So, someone might come in with a little tiny nodule that could be there. But if they didn't have a CT scan, if they didn't get scanned for something else, or if it wasn't detected, no one would have any idea that that nodule that is early lung cancer is just sitting in there in their lungs. So, it's asymptomatic. So, I think having awareness of it is the number one thing.

So, guidelines are anyone who has a significant smoking history essentially. If you've smoked, then I highly recommend that you get a screening CT scan, which is a lower radiation CT scan, to identify those nodules when they're early in the disease course. And then, there's a lot of neat stuff that is coming out that we can do to detect whether or not these nodules are in fact lung cancer.

So, one of them that I've been using is genetic tests that I look for circulating DNA in patient's blood. So kind of walking you through how it happens. So, let's say someone decides, "Hey, I've been smoking for 20 years," or "I did smoke for 20 years, but I quit five years ago"; regardless, they've been smoking for quite some time and they've never had a screening test done of their lungs and they go and talk to their primary care physician about it and say, "Would I qualify for this?" And absolutely you would. And they get a low-dose chest CT. And sure enough, they have a one centimeter nodule in their lungs.

Well, they would normally get referred to me by that point. I see them and I look at the nodule. And at that time, I take their history and I make a calculation of what percentage. Is the risk? What is the percent risk that this is a malignancy, a cancer? And what is the percent that it's not? And at the same time, I draw their blood and I look for circulating tumor DNA, and that helps me better risk stratify whether or not this is less than 10% cancer, something that I just need to maybe watch or this is like 85%, 90%.

And then, if we determine that it's a high percent of risk of cancer, then we are able to do a biopsy here at Stillwater Medical Center using the latest technology. We have the Ion by Intuitive, which is a robot that I use for bronchoscopy. And that's just a bunch of fancy words saying that I can go down someone's airway while they're asleep and take a biopsy of a small nodule anywhere inside of their lungs with very—it's not invasive, hardly at all. I just go down their airway. I take a little biopsy, I come out and it's about a 45-minute procedure total. And then, they get to go home that same-day. And it has very high diagnostic yield, meaning I find out what the answer is about 96% of the time. And we can quickly turn around and decide whether or not this is the cancer and what to do about it next.

Host: That's incredible. Because in the past, there were a lot of side effects that might come from getting a lung biopsy. Is that true? And maybe this has minimized that a little bit from the patient side.

Daniel Roton, MD: Absolutely. So, traditionally, we broke down biopsying pulmonary nodules that we thought were early cancer in two separate ways. One was a bronchoscopy, which is where a pulmonologist like myself goes down with a camera and uses an ultrasound. But even then, they could only do it if they were real central and we could not do the peripheral nodules of the lungs. And they had to be very substantial in size.

And then, the alternative to that was radiology, taking a biopsy, using CT guidance, and they do it from the outside. Well, if you think about that, you know, you're going through so much more tissue, you're going through the skin, you're going through more nerves, veins, arteries that you have to try to avoid. You're going through the ribs. And there's complications that can happen from that. And then, depending on where the nodule is, you actually have to go in through the lung, biopsy it from the inside. And there's a high-risk of causing a collapsed lung from that. So, the collapsed lung, the risk of that was approximately 20% to 25%, whenever they were doing that type of biopsy. Whereas using the robotic approach that I do, it's less than 1%.

Host: Well, and I know that's another huge difference depending on when you catch lung cancer. Talk to us about that and the importance of early diagnosis.

Daniel Roton, MD: Absolutely. So, if we look at lung cancer overall, like most cancers, we break it down into stages. They're stage I, they're stage II, III and then IV. And really, what determines something's stage is the extent of the disease, where it's at in the body, what is involved, has it spread and to what degree.

Stage I and stage II lung cancers, meaning that they're confined right there, they have not had a chance yet to spread. Those are treatable, and oftentimes curable. The five-year survival of someone who is diagnosed with stage I or stage II lung cancer is significantly higher than someone who is diagnosed with stage III or IV. And so being able to detect these nodules early, meaning stage I, and get them identified, get them diagnosed, and get them treated. We are talking about in five years. This is someone who can say, "Oh yeah, I had lung cancer, but I got it taken care of. And I just had a little bit of surveillance where they just watch it now. But I'm doing great. I don't have any side effects or anything from that" versus someone who it was not treated and it progressed, and now they're stage III, stage IV, looking at short-term survival unfortunately. So, it really is all about trying to find them as early as possible and take care of them while we still have a chance.

Host: Well, and you're partnering too with the cancer center to kind of speed that from the time that you're diagnosed to speed the amount of time that you're put into treatment for that. So tell us a little bit more about that and how you guys work together.

Daniel Roton, MD: Absolutely. So, I'm very proud about this actually. I'm very proud, this is my hometown and we are able to do this. So, we are competing with majority of the big tertiary centers. In fact, I would argue that we're doing it better because we are able to do it quicker oftentimes. So, how it normally works is once someone is in my office and we've made the decision that we are going to biopsy this because it's high-risk, then I am able to usually schedule them in for a biopsy within one to two weeks maximum. Get them in, and get a biopsied. And after that, within five to six days after that, they're already being set up for their first appointment with the oncologist at the cancer center. They've talked to me, we've discussed it at tumor board, and there's already a plan in place. So, what are we going to do about this? That process that a big tertiary care center can take weeks, months unfortunately. And when you're dealing with early lung cancer, every single day matters. You want it as quickly as possible. So, the fact that we have all the latest technology here at Stillwater Medical Center, and then quick turnarounds, it's unbelievable and I'm really happy about that.

Host: And that must feel so good to have an impact on the health and quality of your patients. Talk to me a little bit about that. What does it feel like to help people live longer, fuller lives?

Daniel Roton, MD: It is very rewarding. It is extremely rewarding. I love my job. Not only from the lung cancer side, the lung cancer, obviously. I think the biggest wins that come in to my office are the ones that come in three, six months later or a year later, and I had diagnosed them with lung cancer a year ago.

They went and either had radiation or surgery resection, and they come in and they're cancer-free. The rewarding feeling that I get from that, nothing rivals that. That is the top most. I mean, this is someone who had lung cancer, they don't anymore. They have their life a whole ahead of them. And that is so rewarding.

But I also love all my other patients who—not even lung cancer, but specifically asthma. Asthma is a big deal here in Oklahoma, and I found Stillwater specifically. A lot of my patients make the joke that they were doing just fine as far as their breathing is concerned until they moved to Stillwater, And then they found out that they have an allergy to Stillwater. And it's kind of a joke. But we have a really high cedar pollen rate here in Stillwater, and I think it just agitates a lot of people's allergies, and flares up symptoms of asthma that they didn't even know they had. And they'll come in, they'll see me, and there's a whole host of new therapies that are available for asthma that have never been there before. And they're just newly developed within the last four to five years. And I get these patients on these medications and they come back and they feel a hundred times better and they're able to go about their normal lives. And that's a very rewarding. So, the whole process of my job is whether it's in the ICU, whether it's in the bronchoscopy room, diagnosing lung cancer, whether it's diagnosing someone with asthma and helping them through that, it's rewarding and honest. I couldn't be happier about that.

Host: Breath is so essential to life. You have to have it to live. And so, that's a huge thing, huge win. Talk to me a little bit about how has your perspective on life changed since you've become a physician?

Daniel Roton, MD: Honestly, it's a little cliche, but it is what it is, and that is life is fragile. Life is fragile. And so, you really do need to enjoy every day as a gift. It's a blessing, because we don't know when something might happen, whether it be a horrible accident that winds up in the ICU or a cancer that is diagnosed and just completely changes the trajectory of what you thought you were doing. So really, life is fragile and enjoy every single day to its fullest because not every single day is guaranteed unfortunately.

With that though is how resilient human beings are, especially when they set their minds to it. I think I've learned so much from my patients, the ones who come in and they have that resilient mindset from the get-go. And watching how they handle the steps ahead of them, the diagnostic steps, therapeutic steps, all of the steps ahead of them. Their mentality really shapes how it all goes. And I've learned the most from those types of patients. And I look up to a lot of them. And so, that's probably the two biggest things that I would say I've taken away.

Host: Well, we end every conversation with a challenge to care. So, something that people can do for themselves or for the health of this community to make things better. So, what would be your challenge to care today to our listeners?

Daniel Roton, MD: The biggest one would be if you're having trouble smoking, quitting smoking. I tell my patients, one, I would love to help. There are pharmacological aids out there, but stopping smoking is the single biggest thing that you can do for your health, not only from a pulmonary cancer-wise, but from a cardiovascular risk as well. I think quitting smoking—and I tell my patients don't ever give up. Because you'll have that patient that comes in and they're like, "I've tried to quit 20 times." Well, maybe the 21st is the time that it's going to really take hold. So, do not give up. I know it can be an uphill battle and feel like that sometimes. But that would be the biggest thing.

I think the second biggest thing that I would recommend is if you have had a significant smoking history, then you really do need to have a screening chest CT, a lung cancer screening, CAT scan, because that in and of itself could end up saving your life.

Host: And is that true too? Depending on what profession you're in? Are there certain places where your exposure for lung cancer might be greater?

Daniel Roton, MD: There is, especially depending on what types of inhalants or occupational exposures you are exposed to. So, firefighters are some increased risk. And then, people who are just breathing in a lot of different chemicals and things like that. Not necessarily some of them might be lung cancer, but they're just at increased risk for a lot of respiratory diseases.

And then, asbestos is a very big risk factor. People who've been exposed to asbestos, especially like, 30, 40 years ago. When they might not even be thinking about it now, how much asbestos they were exposed to back then, it could actually be very significant for their health right now.

Host: Well, thank you for being here with us today. I know that hearing this has been encouraging to me that there's always hope for a brighter future and that, too, we're able to make a real difference in our community. The amount of progress that's happened, even just since you came back, is incredible. So, thank you so much. Appreciate you being here.

Daniel Roton, MD: Of course. Thank you very much.